“This certificate says that you obtained your PG in … medical college. Is that right? The MCI inspector asked. Yes, madam, the doctor replied confidently. The inspector took a deep sigh and told him “I was the HOD of SPM at that time in your college and I never saw you there.” The doctor was stunned. In the next room another inspector asked another doctor “this certificate says that you obtained your DMRD degree in Manipal. I am just curious to know how to reach that place as I have to go there next month.” The doctor had no clue. It turned out that both were not doctors and the degrees were fake. They were supplied by a Doctor’s recruitment agency in Hyderabad along with fake degrees, for the purpose of inspection for the medical college in question. There were many other incidents like this in that inspection. The upright inspectors declined to give permission to the college in question and left. But after some time, the same college got recognition with a different MCI team and became a reputed college now. The college establishment was never punished and the MCI team which got kickbacks was never punished. This is not an exclusive story of one medical college. These stories happened in every new medical college in the early decade of 2000 because of the difficulty in satisfying MCI requirements.
The colleges became slightly wiser after this type of blunders and started luring individual doctors with various promises — some doctors would appear only for inspection for monetary return, some doctors would continue as temporary doctors with half-salary, some doctors with sought after and scarce degrees (e.g. Radio diagnosis) would be temporary doctors with full salary. Some doctors in the vicinity of the college also appeared in the inspection purely because of the pleas and requests by the college academic team out of familiarity or closeness to them without knowing the consequences. But even with these measures, there was a lot of trouble in satisfying the MCI requirements for the college establishments as doctors were not willing to work full time in the colleges as the returns were higher in private practice. The Deans of these colleges were under so much pressure that they were ready to recruit any doctor, sometimes even without checking the details.
Even with these changes, it was easy to find the culprit doctors and colleges because of the Attendance registers, IT returns, Salary discrepancies, Address issues (just asking the directions to the quarters where they are supposedly residing is enough to catch them as these doctors arrive only in the morning), number of pathology investigations, number of pathology specimens and amount of cotton gauze purchased etc., the underlying point being, it is very easy to capture the culprits. The fact that only few colleges are implicated in this fraud shows us the gross inefficiency (? Efficiency) and complicity of the MCI inspectors. Some colleges and the doctors are targeted either because they were unlucky to be at a wrong place at wrong time or out of political motivation or their refusal to bend to MCI team.
The point is that these fraudulent activities happened not only in every private medical college but in every newly constructed government college (emotional blackmails during inspections, transfer of doctors between colleges during inspections, filing cases in court and applying political pressure to get the recognition) gave a false sense of security to the doctors that they would never be punished. But they never realised that they are the small fish in this big money game and they are the only people who will be punished if something goes wrong. The doctors are bound to certain ethics but not the colleges or MCI inspectors (they are also doctors…?). Nobody, not even the CBI or MCI have the guts to deal with the big fishes in this game because most of the colleges are owned by big politicians either directly or indirectly.
In the recent episode when 25 doctors from Melmaruvathur Adhiparasakthi college were punished, they had the slightest clue about what could happen to them in case they are caught because all of them were assured by the college that nothing is going to happen. But, all of them were debarred for 3-5 years thereby denying their livelihood. It is almost like putting them in jail for 3-5 years. Once they were suspended, the college managements wriggled away from them and renounced any connections. They even had the audacity to file a case against MCI in the high court regarding suspension of the college for 2 years. And the funny (? serious) thing is, students joined the MBBS course knowing fully well that they may be disqualified if the college lose the case in the court.
I am not trying to support the doctors but I am asking a simple question — when the system is corrupt from top to bottom, why only the individual doctors were punished? Moreover, most of them turned approvers and told the truth to the CBI and the MCI Ethics Committee. Still, they were given maximum punishments. Whenever a punishment is given for the first time, the quantum of the punishment should be lesser and a warning should be issued to medical fraternity that the quantum would be much higher in the future. The punishment should also be applied on a prospective basis, not retrospectively. All the other parties should also be punished — college establishments, MCI inspectors etc, not only the small fellows but this never happened.
The college authorities and the doctors are not the only culprits in this fiasco. MCI has done its bit to promote this ugly behaviour. But, who will regulate the regulators?
1. The MCI authorities formulated a heavy set of rules for constructing a new college, knowing fully well that very few will truly build a college with those requirements (with some of these rules even a big institution can be disqualified). Whether any college can be given recognition depended purely on the discretion of MCI inspector because he/she was never cross-checked. This arbitrary interpretation power given to a MCI inspector made him or her a god during inspections (and believe me, some really behave like one) and some of them readily bent the rules if their demands were fulfilled (we had a nickname for them – Suitcases). Actually for doing a semi-clerical and investigative job like this, doctors are not the ideal candidates.
The first step is to stop de-recognition of the colleges. We have to stop talking in round numbers of 50, 100 and 150 students. MCI should get the details of the colleges through 2 independent monitoring agencies (or accreditation agencies) and depending on that (infrastructure, faculty and patients), a suitable number (of students) can be given to each college.
2. MCI authorities didn’t give even slightest bit of thought to geography before giving permission to start a new college (e.g. 7 colleges were given permission in Pondicherry, a small place) — many colleges are mushrooming in South India even now, when the real requirement is in North India. If colleges mushroom in a small place, how can they get patients and doctors? The college authorities have to bribe patients and doctors when they require them during inspections after investing so much in constructing a college and purchasing equipment.
For attracting adequate clinical material and patients, there should be an adequate drainage area for each medical college. But in actual practice these medical colleges are getting concentrated in select areas without any consideration given to the market survey, environmental analysis, catchment area and the availability of the clinical material. As a result of this, the number of patients visiting these colleges became so less that they are not eligible to run even a 25-student batch per year. The students who join these colleges are released into the world without actually seeing and learning about diseases with the result that a patient can approach an experienced RMP with far more confidence than this new batch of students. The enthusiasm and motivation to learn of some of the students is neutralised by the lack of proper infrastructure and patients.
Moreover many students from North India are coming to South India to study medicine and some of them are staying back leading to skewed ratio of doctors. MCI should stop giving permission to new colleges in South India and give incentives to the societies or trusts who want to construct colleges in North.
3. MCI had the statistics of individual specialties and number of doctors available (especially pre-clinical branches), it had even the knowledge that number of professors available in some pre-clinical branches is less than the number of colleges by a large margin. The colleges’ number rapidly increased without taking into consideration the human resource aspect and staffing norms. The number of teachers required for the existing 381 medical colleges is a minimum of 38,000 (70 for 50 students, 90 for 100 students, 125 for 150 students) taking into consideration only the MBBS course. But they continued to give permission to new colleges with the explicit knowledge that they were promoting the flight of doctors from government colleges to private colleges and were creating a salary war between individual colleges. They knew that ultimately some colleges have to resort to this unethical behaviour because of the scarcity.
MCI should allow more non-medical faculty in pre-clinical branches and remove the distinction between faculty of medicine and science in the MSc degrees. MCI should allow temporary doctors and restart the honorary system in certain specialties where there is scarcity. The number of PG seats should also be delinked to the number of teachers especially in non-surgical specialties and should be linked to the medical education and societal requirements.
4. The MCI didn’t computerise its infrastructure and there is a long delay or no response if anyone wants to contact them by a regular or e-mail. It is very easy to track the doctors if a unique ID is given to each faculty member and monthly attendance and salary are updated regularly. In the same way, colleges can submit the census on a daily basis. This will save a lot of work of MCI inspectors and increase the transparency. But by denying computerisation and hiding behind the veil of secrecy, they are trying to protect themselves and the college managements.
A nation always goes through certain stages before it can provide reasonable manpower for the healthcare of the population. Initially there is a dearth of doctors, the supply of which is mostly under government control. This was the situation in India a few years back, which was afflicted by very small number of medical graduates and migration of trained personnel. India had gone beyond the first stage. This second stage should have been a phase of consolidation — increasing the number without compromising the excellence, efficiency and quality — not a process of destruction. The government allowed private players in medical education — there was nothing wrong in this. When private players respond with certain self-control and responsibility, the nation benefits from that move. But when they try to gain unreasonable profit from this move, without necessary services in return, the nation suffers. The later one happened in India, which culminated with the arrest of the MCI Director. Essentially, black money was channelled towards setting up some of these colleges and then many people with black money without proper qualifications joined these colleges paying black money and getting a black degree which allowed them to do black deeds in the society — essentially everything about the present nexus is black, destroying in this process, health infrastructure and the place of doctor in the society.
It is true that most of the colleges are under a lot of financial pressure and losses (if they show white balance sheets), as they have to bear the costs of building the college and maintaining it. As every new advance in medicine is expensive, it is very difficult to cut down costs, lest they would be out of race. The government fixed the rates of MBBS / MD fees using an archaic process without taking into consideration the spiralling and continuing costs. Unable to withstand the financial pressure, many institutions decreased the quality of education and resorted to the capitation fees higher than fixed by the court and government. The government fee structure drove them to indulge in the corrupt activities. If a proper uniform qualifying exam is kept and a proper fee is fixed, the system will become more transparent and black money transactions can be eliminated.
In the 19th century, there were over 400 medical schools in the United States. By 1910, the number was reduced to 148 medical schools and by 1930 the number totalled only 76. Many early medical schools were criticized for being diploma mills that turned out quacks. Abraham Flexner (who in 1910 released the Flexner report with the Carnegie Foundation), the Rockefeller Foundation and the AMA are credited with laying the groundwork for what is now known as the modern medical curriculum and fixing up a proper regulatory system. Something of this sort should happen in India.
I am not trying to justify what some doctors have done to help the college establishments. But they should not be made scapegoats in the current farce. The MCI is equally responsible for the fiasco. We placed a system for starting new colleges and saw how it worked (how it malfunctioned) and how some people used loopholes in this to benefit themselves. We learnt some lessons from this fiasco and knew how to make it work properly. It is high time we stop the present witch hunting and place an efficient regulatory system and plug the loopholes. Sanity will prevail only when everyone is made accountable and start afresh in improving the medical education structure.